Foster Care Intake Checklist Placement Dateencouragefostercare.org/wp-content/resources/... ·...

2685 Armstrong Road, PO Box 765 – Wooster, OH 44691 Phone: 330-345-7949

Foster Care Intake Checklist

Client Name: Placement Date:

☐ Intake Form

☐ Child Care Agreement (copy to FP @ placement)

☐ Placement Agreement/ ICCA from County (copy to FP @ placement)

☐ Copy of FCA Referral Sheet/ County Assessment

☐ Clothing Inventory

☐ Releases of Information

☐ Copy Birth Certificate

☐ Copy Social Security Card

☐ Copy of Medicaid Card

☐ Client Rights, Responsibilities and Grievance Procedures

☐ Consent for Treatment

☐ MITS Agreement

☐ Verification of Receipt of Notice of Privacy Practices

☐ Notice of Privacy Practices (provided to client)

☐ Provisional Diagnostic & Individualized Service Plan (completed by assigned clinician)

☐ Behavior Support Plan (provided copy to Foster Parent & Worker @ placement)

☐ Supervision Plan (provided copy to Foster Parent @ placement)

☐ Release of Information

FC Coordinator (sign/ date): __________________________________.

FC Director (sign/ date): _____________________________________.

Placement Intake Information Form

Intake Information

Child’s Name: Date of Birth:


Gender: Social Security #: Race: Ethnicity: Foster Placement: Date of Placement: Placing Agency Name: Length of Placement : Worker Name: Supervisor Name: Worker ph#: Supervisor ph#: Per Diem Rate: Rate Pd to Parent : Region: Placement Type: Medicaid #:

Biological / Adoptive Family Information

Father’s Name: Mother’s Name: Siblings: County of Residence: Visitation with family? Living Arrangements (prior to admission):

Physical / Health Information

Physical Disabilities/ Developmental issues, Health Problems/ Concerns: Explain (include restrictions): Medications (include name & dosages; usages for treatment and prescribing physician): Primary Care Physician (include name, address and date of last physical exam): Dentist name (include name, address and date of last dental exam): Eye Doctor name (include name, address and date of last optical exam):

Mental & Behavioral Health Information

Mental Health Issues / Behavioral Concerns: Explain (include previous diagnoses; treatment history and previous provider information, hospitalizations and dates): Trauma History, Explain:


Previous and/or Current Mental Health Treatment Information: (include agency name, counselor name and phone #): History of harmful behaviors to self and/or others? Psychiatric Medications (include name & dosages, prescribing physician/ psychiatrist):

Education

Current Education Level: Type of Education:

Legal Issues

History of legal issues: Explain: (include arrests and/or disposition; probation officer and dates):

Form completed by agency worker name and date: __________________________________________.

Form received by FC Coordinator name and date: ____________________________________________.

Supervision Plan

Client’s Name: Date of Placement:

Date of Birth: Age:


Date of Plan:

Supervision Needs:

☐ Similar to other children same age (During first 30 days, all children should be carefully supervised).

☐ Child requires ongoing special supervision due to the following (check all applies):

☐ History of sexual behaviors

☐ History of physically aggressive behaviors

☐ History of self-harm/ self-injurious behaviors

☐ AWOL behaviors

☐ Medical needs

☐ Other:

☐In Home Supervision during waking hours:

☐ Similar to children same age

☐ Visual checks every _________ minutes

☐ Constant supervision in the presence of

☐ Children ☐ pets/ animals ☐ sharp objects ☐ lighters/ matches

☐Unsupervised time: ☐ Client is permitted to have ____________ (minutes/ hours) unsupervised as approved by agency

worker in CIRCLE: (home / community / other structured setting)

Foster Parent 1: ____________________________________________ Date: ___________________

Foster Parent 2: ____________________________________________ Date: ___________________

Encompass staff: ___________________________________________ Date: ___________________

Placing agency: ____________________________________________ Date: ___________________

Child Care Agreement

Child’s Name: DOB:

Foster Parent Name:

Address:


Phone Number:

Date of Placement:

As a foster caregiver licensed by Encompass, we agree to the following:

1. To respect the confidentiality of the child's background, medical history, mental health and

educational plan by protecting all written and electronic materials and by sharing information

only on a need-to-know basis.

2. We agree to accept supervision by agency staff and work as part of the treatment team.

3. Should we decide we cannot work with this child, we will give Encompass fourteen (14) days

written notice. We understand that Encompass retains the legal right to remove the child from

our home any time the agency determines it is in the child's best interest.

4. We agree to identify and report suspected child abuse and neglect according to state law and

Encompass policy. We understand that children may be temporarily or permanently removed

from our home in cases of alleged or suspected abuse within the home.

5. We agree not to use corporal punishment or give others permission to use corporal

punishment. We agree to abide by Encompass’ discipline policy.

6. We agree to provide routine transportation to meet the child's need for medical, dental and

optical care, clothing, counseling, participation in school and extracurricular activities as

outlined by the case manager and we will attend to the child's needs for annual physical and

dental exams, and preventative, non-emergency, and emergency medical care. We agree to

schedule a medical exam within the first five (5) days of placement; a dental and optical

exam scheduled within first 30 days (pending completion of previous exams). 7. We agree to provide transportation to and from visits as requested by the county.

8. We agree to inform Encompass at least two weeks in advance when requesting respite services

(unless it is an emergency situation). We understand it is our responsibility to contact other

approved Encompass foster families to arrange respite services then, if we cannot secure

respite on our own, we will contact Encompass for assistance.

9. We agree to support the child's relationship with the birth family as outlined by the case

manager. We will notify the case manager of any attempts by the birth family to visit on an

unplanned basis.

10. Submit timely paperwork to Encompass, including but not limited to, monthly billing

statements, report cards, medication logs, behavioral logs, medical/dental paperwork and

critical incidents.

11. We agree to provide transportation to/ from scheduled counseling / psychiatric appointments

and participate as needed and requested by my child’s clinician.

12. We agree to enroll our child into appropriate school within 48 hours of the time of placement.

13. We agree to notify Encompass immediately of any emergencies / incidents that may arise

pertaining to my child. We agree to provide Encompass written notification within 24 hours

of the time of any incidents.

Encompass agrees to carry out the following responsibilities:

1. Encompass agrees to provide information to you all information provided to us by the placing

agency about the child's current behavioral functioning, strengths, talents, problems, medical

status, and probable length of placement.


2. Encompass agrees to provide a copy of all written intake referral paperwork provided by the

county.

3. Encompass agrees to provide support and assistance to you and the child on a regularly

scheduled basis.

4. Encompass will inform the foster parents of the visitation plan for the child and his/her

biological family. Visits will be _____________________________ at

___________________________.

5. Encompass will provide 24-hour crisis intervention. The after-hours phone number to call is

330-621-1696 for the Wooster region and 216-475-9336 for the Cleveland region. During

business hours please call the Encompass office in your region.

6. Encompass will pay a daily rate for the child in the amount of _________. The payment is to

be used for shelter, food, clothing, and other needs of the child (ren).

7. These payments will be made by direct deposit into the account you have provided between

the 19th and 21st day of each month for the services provided during the previous month.

8. Encompass will reimburse gas mileage at the rate of .35 (thirty-five cents) a mile for

transportation to and from visits with biological families, respite, and counseling/medical

appointments that are over 50 miles round trip. Mileage reimbursement for transportation less

than 50 miles round trip must be pre-approved by the director of foster care and adoption. All

other transportation is covered by your per diem.

9. The custodial agency will provide for health care costs.


Behaviors Not Described in Referral Paperwork:

I/We state that I/We have reviewed and will comply with the requirements of this document and

other applicable foster caregiver rules. (ODJFS Rules & Regulations).

I/We understand that this agreement is effective until the child is no longer placed in my/our home.

Signatures:

Foster Father & Date:

Foster Mother & Date:

Encompass Staff and Date:


Clients Rights, Responsibilities and Grievance Procedures

Please review this document carefully. The professional providing services to you will answer any questions you have during your initial

service appointment.

The purpose of this document is to give you information concerning your rights and responsibilities as a client receiving professional services.

It also gives you information about how you can let us know if you believe your rights have not been respected as outlined in this document.

Client Rights

(1) The right to be treated with consideration and respect for personal dignity, autonomy and privacy.

(2) The right to service in a humane setting, which is the least restrictive feasible and the right to schedule a service appointment during regular business hours. Business hours are generally M-F 8:30a-5:00p. Evening appointments will also be available.

(3) The right to be informed of one’s own condition, of proposed or current services, treatment or therapies, and treatment alternatives.

(4) The right to consent to or refuse any services, treatment, or therapy upon full explanation of the expected consequences of such consent or refusal. A parent or legal guardian may consent to or refuse any services, as available, either directly or by referral.

(5) The right to a current, written individualized service plan that addresses one’s own mental health, physical health, social and economic needs, and that specifies the provision of appropriate and adequate services, as available, either directly or by referral.

(6) The right to active and informed participation in the establishment, periodic review, and reassessment of the service plan.

(7) The right to freedom from unnecessary or excessive medication, restraint, or seclusion.

(8) The right to participate in any appropriate and available agency service, regardless of refusal of one or more other services, treatments or therapies or regardless of relapse from earlier treatment in that or another service, unless there is a valid and specific necessity which precludes and/or requires the client’s participation in other services. This necessity shall be explained to the client and written in the client’s current service plan.

(9) The right to be informed of, and refuse any, unusual or hazardous treatment procedures.

(10) The right to be advised of and refuse observation by techniques such as one-way vision mirrors, audio or video recordings, or photographs.

(11) The right to have the opportunity to consult with independent treatment specialists or legal counsel, at one’s own expense.

(12) The right to confidentiality of communications and confidentiality of all protected health information within the limitations and requirements set forth by various funding entities, certifying entities, and state or federal statutes unless disclosure of


information is specifically authorized by the client, a parent or legal guardian of a minor client, or a court appointed guardian of an adult client.

(13) The right to be informed of issues that exist related to the difficulty of maintaining the confidentiality of electronically transmitted communications.

a. Awareness of all authorized or unauthorized users including family members and fellow employees who have access to any technology clients may use in the counseling process is recommended.

b. Recommended all emergency situations are referred to 911 or the crisis hotline when the counselor is not available.

(14) The right to be informed in advance of the reason(s) for discontinuance of service and to be involved in planning for the consequences of that event.

(15) The right to receive an explanation of the reason for denial of services.

(16) The right not to be discriminated against in the provision of service on the basis of religion, race, color, creed, sex, national origin, age, lifestyle, physical or mental handicap, or developmental disability.

(17) The right to know the cost of services.

(18) The right to exercise any and all rights without reprisal in any form. When a client exercises his/her rights, he/she will continue to receive uncompromised access to service.

(19) The right to have access to one’s treatment records, unless access to particular identified items of information is specifically restricted for clear treatment reasons or by state or federal statutes. The person restricting information shall explain to the client, and the other persons authorized by the client, the factual information about the individual client that necessitates the restriction. The restriction must be renewed at least annually to retain validity. Any person authorized by the client may have access to information specified by the client. Clients shall be informed in writing of agency policies and procedures for viewing or obtaining copies of personal records upon request.

(20) The right to have oral or written instructions for filing a grievance. The right to file a grievance is not time limited. If you need assistance in filing a grievance or want further information, please contact Ruth Aubrey, Grievance Officer. Ruth can be reached at (330) 345-7949 or you may write her at Encompass Christian Counseling, Foster Care & Adoption, PO Box 765, Wooster, Ohio 44691. In the event that Ruth Aubrey is unavailable, you may file a grievance with Kevin Hewitt, Executive Director at the same phone number and address listed above. A grievance unresolved through this agency may be appealed to:

Mental Health Recovery Board

of Wayne and Holmes County OR

2345 Gateway Dr. Suite C

Wooster, Ohio 44691

(330) 264-2527

Ohio Department of Mental Health

Eighth Floor, Rhodes State Office Tower

30 East Broad Street

Columbus, Ohio 43266-0414


Client Responsibilities

(1) The responsibility to inform the professionals serving you of all important information related to your reasons for seeking services.

(2) The responsibility to actively participate in the services being provided.

(3) The responsibility to attend scheduled appointments or provide 24 hours notice when unable to attend.

(4) The responsibility to pay for services rendered in a timely manner.

I have read this document and anything I don’t understand has been explained to me. I understand that services may be

discontinued if I do not fulfill my responsibilities as outlined in this document.

_______________________________________ ______________________________________________

Encompass Staff (signature) Date Client or Parent/Guardian of Minor (signature) Date

_______________________________________ ____________________________________

Encompass Staff (print name) Client or Parent/Guardian of Minor (print name)

Encompass is a service of Christian Children’s Home of Ohio

Revised: Shawn Pedani, 20150827

Page 2 of 2


MITS Agreement

To receive mental health services paid for by public funds, you must provide required information so we

can bill MITS (Medicaid Information Technology System) and the state of Ohio Medicaid system can pay

us for your services. This information includes but is not limited to the client’s Social Security Number,

Medicaid Billing Number and any other insurance coverage that may exist. If other insurance coverage

exists, you must provide the insured’s Social Security number and date of birth.

All information will be kept confidential, consistent with state and federal law, Name Identifying

information will be used only to pay for services provided to you. Demographic information will be kept

without your name attached, and reported to the state departments and the Ohio Health Care Data

Center. This information will be kept for up to seven (7) years after you have received services, and only

demographic information will be kept after that time.

For questions or additional information, please contact Karon Grier, Medicaid Billing Specialist at

330.345.7949.

I hereby request that CCHO/ Encompass Christian Counseling, Foster Care & Adoption bill the charges

for any eligible services. I authorize payment of benefits to the agency for services provided. I also

authorize the release of any treatment information necessary to process the claim to MITS for the

purpose of determining benefits payable in connection with my claim.

Name of Client (Please Print)

Client Signature (Guardian/ Parent if minor) Date

Updated 20150827


Verification of Receipt of Notice of Privacy Practices

In compliance with federal legislation involving the Health Insurance Portability and Accountability Act

of 1996 (HIPAA), Christian Children’s Home of Ohio / Encompass Christian has created a notice outlining

the way it handles, discloses, and protects client Protected Health Information. I have been given a copy

of this notice and understand that I may direct questions about the notice to CCHO’s Privacy Officer. I

may also make requests about the use and disclosure of my Protected Health Information or I may file a

complaint about possible violation of these privacy practices by following the processes outlined in the

notice.

Name of Client (Please Print)

Print Name of Guardian (if minor) Relationship to Client

Client Signature (Guardian/ Parent if minor) Date

Updated 20150827


CONSENT FOR TREATMENT

I understand Christian Children’s Home of Ohio (CCHO)/Encompass Christian Counseling, Foster Care & Adoption

is a mental health agency certified through the Ohio Department of Mental Health to provide a wide range of mental

health services. I have received copies of the agency’s policy on payment of fees, statement of Client Rights and

Grievances, and Notice of Privacy Practices. I agree to the terms stated in those documents.

Benefits of mental health services may include improved ability to cope with problems of daily living, improved

relationships with others, skill development in areas such as communication and assertiveness, and growth in the areas

of personal goals and values. I understand that in order to resolve difficult life issues, treatment may involve discussion

of unpleasant experiences and explorations of painful feelings that can result in increased emotional strain. I

understand that review and consultation of my treatment including confidential information with supervisors is a

regular part of mental Health Services.

While I expect benefits from these services, I fully understand that, due to factors beyond Christian Children’s Home

of Ohio/ Encompass control or other factors, such benefits and particular outcomes cannot be guaranteed.

In consideration of the above information, I hereby consent to receive mental health services at Christian Children’s

Home of Ohio/ Encompass. I agree to fully inform the mental health professional providing service to me of the

nature of my problem(s) or concern(s) and to actively participate in the development and implementation of my

individual service plan. I further consent to the use and disclosure of my protected health information for payment

and healthcare operations purposes as outlined in the Health Insurance Portability and Accountability Act of 1996

(HIPAA) and in the Notice of Privacy Practices. I understand that it is the policy of Christian Children’s Home of

Ohio to obtain the written permission of a client prior to disclosing protected health information for treatment

purposes.

In addition, my initials on items listed below, indicate my consent to the use of and awareness of CCHO’s limits of

liability, confidentiality and financial responsibility in regards to:

_____ Third Party Power of Attorney (obtain form to be notarized from receptionist) _____ My responsibility to notify co-parent or other custodial party of decision to treat a minor child as per any

legal agreement between parties. _____ Shared parenting: Either parent may give consent for their minor child if the parents are not divorced. If

the parents are separated, but have not completed court proceedings, then either parent may provide consent. If the parents are divorce, the parent that has legal custody or is the custodial parent of the minor should give consent. If all reasonable attempts have been to obtain consent from the custodial parent, and if the child is in need of medical treatment and a delay of care would result in an adverse outcome, the signature of the noncustodial parent may be obtained. In the effect of shared parenting (i.e., both parents have legal custody), the signature of either parent will suffice.

_____ The use of audio/video taping or observation window during client’s session for therapeutic use with client

or guardian. _____ The use of text, e-mail or cellular phone in delivery of services could compromise my confidentiality. _____________________________________________________________________________________

Name of Client Relationship to Client of a minor

_____________________________________________________________________________________

Signature of Client or Guardian/Custodian if a minor Date

___________________________________________ Revised 20150827

CCHO/Witness Signature


Behavior Support Plan

Acting Out Behaviors (Describe of problem behaviors, history of out of control behaviors)

Medical Concerns & Contraindications (Identify and include report from youth’s physician)

Psychological and Developmental Concerns & Contraindications (Identify and include summary from youth’s therapist)

Identifiable Triggers

INTERVENTIONS: Type of interventions which may be used (Check below all that apply). Interventions not checked are contra-indicators and may not be used.

Use of physical activity Use of breathing

relaxation Use of physical

restraints Use of music

Use of diversion Use of verbal de-escalation

Use of isolation Use of writing/drawing

Use of reminder charts Use of “Time-out” Use of sensory interventions

Alternative interventions: Click here to enter text.

Provider Signature/Credentials

Date

Supervisor Signature/Credentials (If applicable)

Date

Foster Care Intake Checklist Placement Dateencouragefostercare.org/wp-content/resources/... ·...

Documents

Transcript of Foster Care Intake Checklist Placement Dateencouragefostercare.org/wp-content/resources/... ·...